麻豆传媒

THE evil weed, cancer sticks, coffin nails . . . From the names smokers use
to describe their habit it鈥檚 obvious they know they should quit. Politicians and
doctors agree. The orthodox view is that slowly and surely, via creeping
prohibition, tax hikes, education and medical intervention, people must be
weaned off their deadly addiction until eventually, one fine day, the last
smoker stubs out their last ciggy鈥攁nd we鈥檒l all live happily ever
after.

Fat chance. Smoking is on the up worldwide and the trend shows no signs of
slowing. There鈥檚 about a 1 per cent increase in cigarette consumption every
year, with the number of smokers worldwide now standing at about 1.1 billion and
expected to rise to 1.6 billion by 2025. Small decreases in a few Western
countries have been outweighed by people in developing nations taking up the
habit with gusto. And even in much of the West, smoking among young people is
rising, too.

The orthodox approach isn鈥檛 working. Maybe it鈥檚 time to think the unthinkable
and accept that a tobacco-free world isn鈥檛 going to happen. But learning to live
with tobacco is not the same as leaving smokers to their fate. There are
well-researched strategies to cut deaths from smoking that have little to do
with propaganda or prohibition. They receive scant attention from governments
because they鈥檙e just not politically acceptable. But they work.

Take Sweden, for example. It was the only country to meet the World Health
Organization鈥檚 target of reducing smoking prevalence to 20 per cent of the
population by 2000. Its success is all down to a strange cultural predilection
for what might be called 鈥渟ucking tobacco鈥�. No one鈥檚 suggesting that the rest of
us take up the habit, but Sweden points to a new way to save lives.

There鈥檚 no doubt that smoking is a global health problem. Smokers are 25
times as likely to contract lung cancer compared with non-smokers, and run two
to three times the risk of a heart attack. Half of smokers die prematurely as a
direct result of their habit, 4 million a year worldwide.

Yet smokers aren鈥檛 dying of ignorance. They understand the harm their habit
is doing to their health. According to British anti-smoking group ASH (Action on
Smoking and Health), two-thirds of smokers want to quit and half of these
attempt to do so every year. But success rates are dismal. Of those who try
using will power alone, only 5 per cent are sticking to their guns one year
later, according to a 1999 review by England and Wales鈥檚 Health Education
Authority.

The problem is that nicotine is ferociously addictive (麻豆传媒,
13 August 1994, p 10). Once people get hooked, they find it nearly impossible
to give up. Nicotine latches onto receptors in the brain, causing nerve cells to
release the dopamine that produces a pleasurable high. This psychoactive effect
makes users seek the drug out鈥攁 classic element of addiction. In terms of
chemical dependence, doctors rank nicotine as more powerful than heroin and
cocaine.

The orthodox response has been to classify smoking as a 鈥渄isease鈥� and try to
cure it. In the past few years drugs companies have flooded the market with
鈥渟moking cessation products鈥�. Almost all of these are nicotine replacement
therapies鈥攃hewing gum, skin patches, lozenges or inhalers designed to
deliver a dose of nicotine large enough to kill cravings but too small to
produce a high. The idea is that you use nicotine replacement therapy as a
temporary pharmaceutical crutch to keep the pangs at bay while you kick the
habit.

Replacement therapy is possible because nicotine itself is pretty harmless.
True, it does have some stimulatory effects on the nervous system, leading to
raised blood pressure and heart rate. It鈥檚 also toxic, though you鈥檇 have to chew
20 pieces of nicotine gum simultaneously to risk a lethal dose. Perhaps more
seriously, nicotine itself is a mild carcinogen
(麻豆传媒, 2 December 2000, p 10)
and promotes blood vessel formation, which can help the
growth of existing tumours. But the consensus is that smokers aren鈥檛 dying from
what they are actually addicted to. It鈥檚 all the other chemicals in tobacco
smoke that do them in.

Burning tobacco gives off around 4000 compounds, at least 60 of which are
known to cause cancer. Cigarette smoke also contains carbon monoxide, which
reduces the blood鈥檚 ability to carry oxygen and so puts a strain on smokers鈥�
hearts and lungs.

Finding new ways of delivering nicotine satisfies short-term cravings, but
its success rate in getting people to quit smoking isn鈥檛 good. Without
additional support, such as weekly counselling sessions and telephone helplines,
90 per cent of people who try nicotine replacement therapy start smoking again
within a year. Even with the most successful drug, GlaxoSmithKline鈥檚 Zyban,
around 85 per cent of quitters fail.

So how come Sweden does so well? The answer is that smokers there aren鈥檛
faced with the quit-or-die dilemma. Instead of using a nicotine replacement
therapy with the aim of quitting both smoking and ultimately nicotine, they can
continue using tobacco as a recreational drug, safe in the knowledge that it
probably won鈥檛 kill them. It鈥檚 all down to a product called 鈥渟nus鈥�, a form of
moist ground tobacco that you pop between your lip and gum. Snus comes in two
forms, either loose or packed in small portions like miniature tea bags. Both
deliver nicotine direct to the bloodstream.

Among Sweden鈥檚 3.4 million men, snus is more popular than smoking: about 19
per cent use snus and 17 per cent smoke. That鈥檚 easily the lowest rate of
smoking in Europe鈥攈alf the rate of Norway, for example鈥攁nd it
translates into an excellent health record. Swedish men have the lowest rate of
lung cancer in Europe, according to WHO figures, and the lowest risk of dying
from a smoking-related disease鈥攋ust 11 per cent compared with 25 per cent
in Europe as a whole. Karl Fagerstr枚m of the Helsingborg Smokers鈥�
Information Centre, a smoking cessation clinic, is in no doubt that snus should
take the credit. 鈥淚t鈥檚 very hard to argue that there are other factors
responsible,鈥� he says. 鈥淚t鈥檚 very common to switch from smoking to snus. If they
can鈥檛 give up smoking then I suggest snus because it鈥檚 much less dangerous than
setting fire to tobacco.鈥� Tellingly, about half of snus users are former
smokers.

The evidence that snus improves public health becomes even stronger when you
consider Swedish women. They hardly touch the stuff鈥攐nly around 2 per cent
use it鈥攕o act as a built-in control to the experiment. And their record on
smoking-related diseases is nothing out of the ordinary. Swedish women are just
as likely as any others to die from smoking, and their lung cancer rates are
comparable with those of other Scandinavian countries.

Recreational drug

Snus isn鈥檛 completely harmless. Users increase their risk of cardiovascular
disease by 40 per cent. But that鈥檚 lower than the risk among smokers. And
crucially, snus doesn鈥檛 seem to cause mouth cancer, which is a serious risk with
other forms of oral tobacco. A long-term study of 135,000 Swedish men, published
in the American Journal of Public Health in 1994, found that snus caused no
increase in cancer risk at all. The reason is that snus is cured under
conditions that inhibit the production of carcinogens.

Snus, in effect, is nicotine replacement without the therapy. It鈥檚 a
pleasurable, recreational drug, and users aren鈥檛 under pressure to stop. Swedish
Match, the Stockholm-based tobacco company that dominates the snus market in
Sweden, explicitly promotes its product as a safer alternative to smoking.

The 鈥淪wedish experiment鈥�, as it has come to be known, has inspired some
health campaigners to press for a more enlightened approach to the smoking
epidemic. It鈥檚 a concept they call 鈥渉arm reduction鈥�. 鈥淚f you look at Sweden, we
have a living example of the concept in action,鈥� says Clive Bates, director of
ASH.

Snus on its own will never be the answer. For one thing, few people outside
Sweden have heard of it, though there鈥檚 some tradition of use in Germany and
Denmark. It鈥檚 also illegal. The European Union banned it in 1992 as part of a
general assault on oral tobacco. Sweden negotiated an opt-out when it joined the
EU in 1995.

But the Swedish experiment does suggest that we could tackle smoking more
creatively. In most countries, nicotine replacement therapies are tightly
regulated, sold only in pharmacies as temporary aids for bona fide quitters.
They鈥檙e expensive鈥攊n the US, for example, one day鈥檚 supply of nicotine
replacement therapy can cost half as much again as a pack of 20
cigarettes鈥攁nd product leaflets give strict warnings that using nicotine
replacement therapy while still smoking could trigger a nicotine overdose,
leading to dangerous heart problems. In other words, if you want to use
replacement therapy to help you cut down, whittle down a 40-a-day habit in
stages, or just get through a non-smoking transatlantic flight, you鈥檙e in for an
uphill struggle.

To many anti-smoking activists this is crazy. David Sweanor, legal adviser to
the Canadian Smoking and Health Action Foundation, cites the example of a parent
on a long car journey, desperate to avoid smoking as their child is in the back
seat: 鈥淐igarettes are readily available at their first petrol stop, but nicotine
gum isn鈥檛.鈥� He believes that as well as being an aid to quitting, nicotine
replacement therapies should be available as a consumer product.

But drug regulatory agencies are ultra-cautious. They鈥檙e not convinced by
the argument that chewing nicotine gum for half your life can鈥檛 be as bad as
smoking like a chimney, because it hasn鈥檛 been tested in long-term clinical
trials. 鈥淕oing from a pack a day to half a pack a day is bound to make a
difference to people鈥檚 health,鈥� Sweanor says. 鈥淏ut until you can prove that, you
can鈥檛 get that licence.鈥�

Harm reduction, however, isn鈥檛 the sole preserve of the drugs industry. Some
tobacco companies have decided to take the matter into their own hands by
developing safer cigarettes. Admittedly, they鈥檒l still probably shorten smokers鈥�
lives, but maybe by not quite as much鈥攚hich must be better than leaving
things as they are.

One safer cigarette currently being test-marketed is Eclipse, developed by US
tobacco giant RJ Reynolds. It consists of a tube of tobacco with a heat source
at one end. To 鈥渟moke鈥� it you light the heat source and suck on the other end,
which draws heated air through the tobacco and evaporates the nicotine in a
similar way to hot water passing through coffee grounds
(see Diagram).
Most of the tobacco doesn鈥檛 catch fire and the cigarette doesn鈥檛 burn down. RJ
Reynolds claims that the smoke contains lower levels of 14 known or suspected
carcinogens than ordinary cigarette smoke.

RJ Reynolds test-marketed a similar product, Premier, in 1988 but withdrew it
because smokers didn鈥檛 like the taste. Eclipse has a shot of tobacco in the heat
source to produce a slug of real smoke, but it鈥檚 still not certain that smokers
will take to it.

Other tobacco companies are trying to make actual cigarette smoke safer, by
reducing levels of carcinogens. One American firm, Star Scientific, is staking
its future on a tobacco-curing process that it says reduces the levels of some
carcinogens.

But again, there are regulatory problems. There鈥檚 no point in tobacco firms
investing money in safer products if they are not allowed to make health claims.
And regulators take a dim view of using the words 鈥渟afe鈥� and 鈥渃igarettes鈥� in the
same sentence.

They鈥檝e had their fingers burnt, so to speak, on this before, by low-tar
cigarettes. Regulators were happy to accept health claims, only to find that
鈥渓ight鈥� brands were actually more dangerous. Low-tar smoke is less irritable to
the airways, so smokers inhale more deeply, exposing a greater proportion of
their lung tissue to carcinogens. As a result, lung cancer rates actually rose
after the introduction of low-tar cigarettes
(麻豆传媒, 15 March 1997, p 8).

Despite the regulatory problems, there are signs that health authorities are
starting to take harm reduction seriously. Earlier this year, the US Institute
of Medicine published a report on 鈥減otential reduced-exposure products鈥�,
including snus and nicotine replacement therapy. The key question was whether
harm-reduction products save lives in the long run, or whether their benefits
are outweighed by people staying addicted to nicotine when they might otherwise
have quit鈥攐r even taking up smoking when they wouldn鈥檛 have otherwise.

Backward step

The report was eagerly awaited by harm reduction advocates who hoped it would
back their way of thinking. But they were disappointed. One of the main
conclusions was that there鈥檚 no evidence harm reduction improves public health,
and might even damage it. Far from breaking new ground in tobacco policy, the
report was widely seen by campaigners as a retrograde step.

Joint author Robert Wallace, an epidemiologist at the University of Iowa,
defends the report, saying: 鈥淲e don鈥檛 want people to be misled into thinking
they are taking a product that鈥檚 less harmful to their health when what they
should be doing is quitting. The long-term health effects of these products are
not defined. They certainly should not be able to make claims that they鈥檙e safer
because there鈥檚 simply no evidence.鈥�

Outside the US, however, harm reductionists are gaining ground. New
legislation in the EU will soften the health warnings on snus, replacing 鈥渃auses
cancer鈥� and 鈥渟eriously damages health鈥� with 鈥渃an damage your health鈥� and 鈥渋s
addictive鈥�. The same legislation, due to come into force next year, enjoins EU
scientists to investigate reduced-risk tobacco products. Whether this will pave
the way for snus to be legalised across the EU remains to be seen. But a
showdown is likely when Swedish Match takes the German authorities to the
European Court of Justice for trying to enforce the ban.

The WHO has gone even further. Its most recent report on regulating tobacco
products, published in May, acknowledges that there is a need for new tobacco
delivery systems, and even calls for 鈥渕ore progressive鈥� regulatory methods.

No one sensible is suggesting that harm reduction should replace measures
such as banning tobacco adverts or sales to children. And the single most
beneficial thing an individual smoker can do is quit. But there might be real
public health benefits from pursuing policies that encourage harm reduction when
quitting isn鈥檛 possible.

There are historical precedents. Needle-exchange schemes for heroin addicts
sparked moral outrage when they were first introduced, but they are now seen as
an invaluable tool in reducing the spread of HIV and hepatitis. Harm reduction
for nicotine addicts also entails steps that some view as morally repugnant.
Legislators and doctors will have to start working side-by-side with tobacco
companies, having spent all their professional lives viewing them as agents of
Satan. Perhaps they鈥檙e taking the term 鈥渆vil weed鈥� too literally.